vital signs

tympanic membrane; pull pinna back and upwards to get accurate temperature

the difference between the systolic and diastolic pressures is the pulse pressure, if the client's blood pressure is 130/85 mm Hg, the pulse pressure is 45 mm Hg (130-85=45)

pulse strength levels:

• 0: Absent (no pulse can be felt)

• 1+: Diminished/weak (barely palpable, but present)

• 2+: Normal (easily palpable)

• 3+: Full (stronger than normal)

• 4+: Bounding (very strong/hyperactive)

five phases of korotkoff sounds:

• Phase 1 (Systolic Pressure): first faint, clear tapping sounds appear as blood begins to pass through the compressed artery.

• Phase 2: sound is softer, swishing quality as the cuff continues to deflate

• Phase 3: sound is sharper and much louder, similar to rhythmic, crisp thumps

• Phase 4 (First Diastolic Reading): sounds become noticeably muffled and softer.

• Phase 5 (Second Diastolic Reading): all sounds completely disappear; point where the sound ceases marks your diastolic blood pressure

normal heart sounds:

• S1 (lub) - tricuspid and mitral valve close

• S2 (dub) - aortic & pulmonic valve closure

• abnormal heart sounds:

• S3 - "ventricular gallop" occurs in early diastole

• S4 - "atrial gallop" late diastole

rectal temp: insertion depth of 2.54 cm (1 in)